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Instructions: The following questions are concerned with the past four weeks (28 days) only.
Please read each question carefully. Please answer all the questions. Thank you.
Questions 1 to 12: Please circle the appropriate number on the right. Remember that the questions only refer to
the past four weeks (28 days) only.
10 Have you had a definite fear that you might gain weight? 0 1 2 3 4 5 6
Over the past 28 days, how many times have you eaten what other people would regards as an unusually
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large amount of food (given the circumstances)?
14 … On how many of these times did you have a sense of having lost control over your eating (at the time
you were eating)?
Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e. you have eaten
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an unusually large amount of food and have had a sense of loss of control at the time)?
Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your
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shape or weight?
Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or
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weight?
Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of
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controlling your weight, shape or amount of fat, or to burn off calories?
Questions 19 to 21: Please circle the appropriate number. Please note that for these questions the term “binge
eating” means eating what others would regard as an unusually large amount of food for the circumstances,
accompanied by a sense of having lost control over eating.
NOT
ON HOW MANY OVER THE PAST 28 DAYS ... SLIGHTLY MODERATELY MARKEDLY
AT ALL
How much would it have upset you if you had been asked
24 to weigh yourself once a week (no more, or less, often) for 0 1 2 3 4 5 6
the next four weeks?
If female: Over the past three to four months have you missed any menstrual periods?: YES NO